Working with Survivors of Sexual Abuse

Mark O'Brien, LCSW-R

1. Message to survivors

2. Perspectives necessary for this task

3. Review of Erickson's Developmental Stages

4. Traits & characteristics of families

a. The family process
b. Family messages to survivors of abuse

5. Aftereffects of abuse
a. Severity of aftereffects by type of abuse
b. Symptom constellation
c. The Incest survivor's aftereffects checklist

6. Physical and emotional abuse: four roles

a. Caretaker
b. Perfectionist
c. Rebel
d. Invisible One

7. Goals of treatment

8. Adult survivors - Stages of Recovery

9. Forgiveness? Stages of Forgiveness - role of anger

10. Flashbacks

11. Transference Issues

12.Countertransference Issues
 . , They are survivors. If you don't have respect for
their strength you can't be of any help, It's a
privilege that they let you in - there's no reason
they should trust you - none. You can't know their
terror - it's your worst nightmare come true - a
nightmare. from which you never awaken,
\
It's
unrelenting. There has been no safety: no one, no
time, no place, no thing - all was tainted. Hope
was obliterated - time and time again. That they
are in your office is in itself a supreme act of
valor.

---·-·-··
 Working with Survivors of Abuse
Part II: Uncovering the Abuse
"Presented by Mark O'Brien, CSW
March 30, 1994

More important therapist perspectives/qualities:

- Have to believe healing is possible from this man-made trauma

- Have to be able to witness great pain
- Have to be willing to believe the unbelievable.
- Present a healthy role-model. Be genuine, honest, predictable.

Important Issues:

- Therapist gender may be important to the patient.

- Abuse is never fantasized - it is real history.
- Survivors feel that their body betrayed them and their body is the enemy.
- Allow expression of anger: validate anger as a healthy response. Anger is empowering.
- Survivors need to forgive themselves.
- Validate and normalize coping mechanisms.
- Assist in building informal support system.
- Encourage the survivor to feel in order to re-integrate the affect.

Things to A void:

- ~void giving the message that the patient is in.fil!Y way responsible for the abuse.
- Avoid minimizing the abuse.
- Avoid spending time trying to understand the abuser.
- Avoid implying that the survivor needs to forgive the abuser.
- Avoid implying that sexual preference is the result of abuse.
- Avoid touching without permission.
- An authoritarian stance can be a problem because it risks re-abusing the patient.

Uncovering the Abuse:

- Emotional abuse is always a component of sexual and physical abuse.

- Look for "red flags" that alert you to _abuse.
- Ask for specifics and details.
- Rephrase and return to subject.
- Use creative modalities, methods of expression other than verbal. Survivors often operate in other sensory modes
such as visual or kinesthetic.

MIKE A:WORKING
 Erickson's Developmental Tasks

Trust vs. Mistrust - Hope (Infants, O to 1 year)

Áutonomy vs. Shame & Doubt - Will (Toddlers, 2 to 3 years)

• Main Question: "Can I do things myself or must I always rely on others?"

Initiative vs. Guilt - Purpose (Preschool, 3 to 5 years)

• Main Question: "Am I good or am I bad?"

Industry vs. Inferiority - Competence (Childhood, 6 to 11 years)

• Main Question: "How can I be good?"

Identity vs. Role Confusion - Fidelity (Adolescents, 12 to 19 years)

• Main Question: "Who am I and where am I going?"

Intimacy vs. Isolation - Love (Young Adults, 20 to 40 years)

• Main Question: "Am I loved and wanted?" or "Shall I share my life with someone or live
alone?"

Generativity vs. Stagnation - Care (Middle Adulthood, 45 to 65 years)

• Main Question: "Will I produce something of real value?"

Integrity vs. Despair - Wisdom (Seniors, 65 years onwards)

• Main Question: "Have I lived a full life?"

 The Family Process
Two broad famih· tvpes:

L Normal appearing
2. Chaotic

Characteristics of each:

l. Isolated socially, psychologically and physically

2. Boundary problems - too rigid outside too permeable inside
3. Enmeshment within the family yet emotional and physical deprivation
4. Role reversal between parent and children
5. Usually "low touch" families with affection expressed sexually
6. Power imbalance and sexual and communication problems between spouses

Patterns of intergenerational transmission:

l. Incest as a symptom of transgenerational family process with intrapsychic and

interpersonal dimension (Calaf, 1987)
e
2. Denial and dissociation are primary mechanisms of the intrapsychic process .
3. Both parents may have been emotionally deprived themselves, physically and/or
sexually abused or witnesses to such abuse in their families of origin
4. Destructive triangulation (Rist, 1979) children meet the needs of parents while
their needs go unmet. This process occurs across generations
5. Shame (Fossum & Mason, 1986)
6. Inconsistency of parental response
7. Co-dependency

Familv rules and injunctions:

l. Double bind communication

2. Don't feel
3. Stay in control at all times
4. Deny what is happening - disbelieve your own perception
5. Do not trust yourself or anyone else
£. Do not tell - you will not be believed nor will you == helped
7. Be ashamed of yourself ~ you are to blame
8. Idiosyncratic. rules
I'

.,
'IL

. .
FAMILY MESSAGES TO SURVIVORS OF CHILDHOOD SEXUAL ABUSE

* Don't feel. Keep your feelings in check. Do not show your feelings,
especially anger. .

*Bein cohtrol at all times. Do not sho~ weakness. Do not a~k for help.

* Deny what is reë;llly happening. Disbelfeve your own senses/perceptions.

Lie to yourself and to others.

* Don't trust yourself or anyorie else. No one is trustworthy.

* Keep the secret. If you tell you will not be believed and it will not
get help.

* Be ashamed of yourself. You are to blame for everythihg.

 Common Aftereffects of Incest ·
Occur at the time of abuse and later; may be chronic or may deuelop
in delayed fashion

1. Symptoms of traumatic stress;

• numbing
• reexperlenclnq other reactions to trauma

2. Emotional effects;
• depression uulnerability
• amdety rage
• guilt loss
• grief fear of loss of control

3. sett-perceptlons and cognitiue effects;

• cognitiue distortions
• self-blame, and self-denigration (Jehu, 1988)
• shame

4. Somatic effects;
• somatic disorders and somatization
• directly and indirectly related to focus of abuse
• physiological changes and dysregulation

5. seauat effects;
• sexual emergence
• sexual identity
• arousal, response and satisfaction
.
(Maltz e, Holman, 1987) ·
.

6. Interpersonal relating and functioning;

• mistrust, relational and intimacy disturbances
• other directedness, acting in, and acting out (Briere, 1989)
• family and parenting difficulties

7. Social effects; .
• inability to tunctlnn, usually ouer functioning, occupationally and
socially
• antisocial, deuìant behauiors
• comnutstue and adrìtctlue behauiors
,¡"{ ,r.• " ' ' ,. \ ' ,: ' - ' '
•

Severity of Aftereffects by Type of Abuse

The variables of incest most related to severity of aftereffects are:

1. Duration and frequency

2. Type of sexual activity

3. Use of force

4. Child's age at onset

5. Age, gender and relatedness of perpetrator.

6. Child's submission or participation .

7. Overt or disclosed incest with lack of assistance

8. Parental reaction

9. Institutional response

Many of these are interrelated.

· The child's personality and moderators can also affect response.

. Symptom Constellation of Adult Survivors
· · (cont.) ··

e History of revictimization

e History of self-injury

~ History of suícídalíty, suicide attempts

e Polarities of behavior .

e Difficulty establishing therapeutic alliance.

... multiple previous diagnoses and therapies
-· abuse by a previous therapist ·

0 Amnesia
- past·
= current

® Negative identity/shame; identity diffusion

® Anger (often unrecognized and/ or displaced)

® Grief

7
 //

The Incest Survivors' Aftereffects Checklist

Do you find many characteristics of yourself on this list? If so, you could be: a survivor of ·incc:st.

l. ·Fc:ar of bc:ing. alortë. in che: dark, of sleeping alone; nightmares, nigh~ 'terrors (especially of
pursuit, threat, entrapmenr)
2. Swallowing and gagging sensitiviry; repugnance to water on one's face: when bathing or
swimming (suffocation feelings) ..
3. Alic:nacion from the: body-not ac home in own body; failure: to heed-body- signals çr take
care: of one's body; poor body image; manipulating body size: to avoid sexual attention
4. Gasrrointc:srinal problems; gynecologic.al disorders (including spontaneous vaginal infec-
tions); headaches; arthritis or joint pain
5. Wc:aring a lot of clothing, c:vc~_ i:g summer; baggy clothes; failure to remove clothing even
when appropriate: to do so {~~rê:._swÙruiîing_, bathing, slec:ping); extreme :q:qui~ement for
privacy whc:n using bathroori:i~- · · · · ·· ··' ·.
6. Eating disorders, drug or alcohol abus~ {or rÖta! abstinence}; other addictions; ~ompu~ivc:
behaviors
7. Self-destructiveness; skin carving, self-abuse:
8. Phobias
9. Need to be: invisible, perfect, or perfectly bad
10. Suicidal thoughts, attempts, obsession (including "passive suicide")
11. Depression (somc:cimc:s paralyzing); sec:min~~ baseless crying
U. Anger issues; inabiliry to recognize, own, or ~pr~
~ngcr; fur of actual or imagined rage;
constanr2~n'geÏ:; intense hostility toward ~n}e·~-~~~Ô¡:~~ic group of the perpetrator
... : - . .. .:-~-
13. Splitting (depersonalizarion); going into shock, shutdo~~ in crisis;· a stressful situation al-
ways is a crisis; psychic numbing; physical pain or numbness associated, with a particular
-memory, emotion (e.g., anger), or siruation (e.g., sex)
14. 'Rigid concrei of one's thought procc:ss; humorlessness or extreme solemniry
15. Childhood hiding, hanging on, cowering in corners (security-seeking behaviors); adult ner-
vousncss ov:.r being watched or surprised; feeling watched; srarile response
16. Trust issuesi 'inabiliry to trust (trust is nor safe); rotal trust; trusting indiscriminately
17. High risk taking ("daring rhe fates"); inabiliry to cake: risks
18. Boundary issues; co~rrol, power, terrirorialiry issues; fear of losing conrrol; obsessive/corn-
pulsive behaviors (attempts to control things chat don't matter, just to control somc:rhing)
19. Guilt, shame; low self-esteem, feeling worthless; high appreciation of small favors by others
20. Pattern of being a victim (victimizing oneself after being victimized by others), especially
sexually; no sense of own power or right to set limits or say no; pattern of relationships with
much older persons (onset in adolescence) ·
 21. Feeling demand to .. produce: and be: loved"; instinctively knowing and doing what the: other
person needs or-wants; ·rdationships,mc,;¡g..mg.,u.adcoffs.,(love was .raken, not givc:n)
22. Abandonment issues
_; · 23. Blocking-out some period o_f early years (especially 1-12), or a specific person or place:
24. Feeling of -~rrying ~n awf~Í sccre~; urge: t~ tell, fc:~r of its being revealed; certainty that no
one will listen; being generally secretive; feeling "marked" (the "scarlet letter")
25. Feeling crazy; feeling different; feeling oneself to be unreal and everyone else to be real, or
vice: versa; creating fantasy wodds, relationships,. or identities (especially for women: imag-
ining or wishing self to be male, i.e., not :r victim)
___ 26. Denial: no awareness at all; repression of memories; pretending; minimizing ( .. it wasn't that
bad"); ~aving dreams ai: memories ("maybe it's my imagination"); strong, deep, "inappro-
priate" negative reactions to a person, place, or event; .. sensory flashes" (a light, a place, a
physical feeling) wimQUt a sense of th_etr.:_~aning; remembering the surroundings but _nqt th~
event
_ 27. Sexual issues: sex f~els •icfìrry'- ~.-â,v1:b¡ron ·to bçirîg.ì,touched, especially ïri gynecological exam;
0

strong aversion co (or need for) pari:ìéular sex acts; '(é~ling betrayed by one's óody; trouble
integrating sexuality and emotionality; confusion or overlapping of affection, sex, domi-
nance, aggression, and violence; having to pursue power in sexual arena which is accually
sexual acting out (self-abuse and manipulation, especially among women; abuse of ochers,
especially among men); compulsively "seductive" or: compulsively asexual; must be sexual
aggressor or cannot be; impersonal, "promiscuous" sex with strangers concurrent wich in-
ability to have sex in intimate relationship (conflict between sex and caring}; prostitute, strip-
per, "sex symbol," porn actress; sexual acting out to meet anger or revenge needs;
.. sexaholisrn"; avoidance; shutdown; crying after orgasm; all pursuit feds like violation; sex-
ualizing of meaningful relationships; erotic response co abuse or anger, sexual fantasies of
dominance or rape (Noce: Homosexuality is not an aftereffect)
28. Pattern of ambivalent or intensely conflictive relationships (intimacy is a problem; also focus
shifted from incest issues)
29. Avoidance of mirrors (connected with invisibilicy, shame/self-esteem issues, distrust of per-
ceived body image)
30. Desire to change one's name (to disassociate from the perpetrator or to take control through
self-läbeling) -:-
31. Limited tolerance for happiness; active withdrawal from happiness, rc:lucrance to trust hap-
piness ( .. ice=rhin ")
_ 32. Aversion t~ making noise •(including during sex, crying, laughing, or other body functions);
verbal hypervigilance (careful monitoring of one's words); quiet-voiced, especially when
needing to be heard
33. Stealing (adults); stealing and starting fires (children)
34. Multiple pc:rsonaliry

Copyright «:i 1985, 1986, 1987, 1988, 1989 by E. Sue Blume

 Goals of Treatment
1. Development of a commitment to treatment and the
establishment of a therapeutic alliance

2. Acknowledgement and acceptance of the occurrence of

the incest

3. Recounting the incest

4. The breakdown of feelings of isolation and stigma

5. The recognition, labeling and expression of feelings

6. The resolution of responsibility and survival issues

7. Grieving

8. Cognitive restructuring of distorted beliefs and stress

responses

9. Self-determination and behavioral changes

1 O. Education and skill-building

 ADULT SURVIVORS - STAGES OF RECOVERY

l. The Decision to Heal

2. The Emergency Stage

3. Remembering

4. Believing It Happened

5. Breaking Silence
6. Understanding That It Wasn't Your Fault

7. Making Contact W~th the Child Within

8. Trusting Yourself
9. Grieving and Mourning
10.Anger - the Backbone of Healing
11.Disclosures and Confrontations

12.Forgiveness?
13.Spirituality

14.Resolution and Moving On

 Stages of Forgiveness
STAGE ONE: IDENTIFY PERPETRATOR AND TRANSGRESSION
I know who it was that has affected me negatively.
I know what specific behavior(s) it was that has been physically, emotionally, or spiritually damaging to me.

STAGE 1WO: IDENTIFY, EXPERIENCE, AND PROCESS THE EMOTIONS

• I have felt the emotions associated with the offensive, damaging behavior. I have found a safe place to
process these feelings.
If it was safe to do so, I have spoken to the person regarding the adverse effects I endured as a result of his/
her behavior.
If it was not safe to do so, I was able to do it in therapy using an imaginary technique (e.g., role playing,
psychodrama, the empty chair, etc.).

STAGE THREE: UNDERSTAND THE NEED FOR FORGIVENESS

• I understand the benefits of forgiveness.
• I have reached a point where I recognize what has transpired, have begun developing compassion for
myself, and am now able to see the perpetrator as a human being.
Important Distinction: Many people, including clergy members, philosophers, psychotherapists, and
psychologists, erroneously believe that full forgiveness requires the victim to accept the perpetrator back
into the relationship. What is actually required of the victim is that (s)he accept the perpetrator back into the
human race (i.e., (s)he is no longer stripped of his/her humanity, regardless of whether the victim chooses to
reestablish a personal relationship with him/her).
As Joan Borysenko states in Guilt Is the Teacher, Love Is the Lesson
Forgiveness is not a lack of discrimination whereby we let all the criminals out of prison: it is an attitude that
permits us to relate to the pain that led to their errors and recognize their need for love. (1991, p. XXX)

STAGE FOUR: SET CLEAR BOUNDARIES

I have set clear boundaries with the perpetrator:
• I understand the need for and my right to protect myself.
I feel competent in setting and maintaining these boundaries to keep me physically and emotionally safe.

STAGE FIVE: INTEGRATE THE PAST AND BEGIN RECREATING THE FUTURE
• I have made an internal choice to forgive and a have willingness to recreate a meaningful life for myself.
 Flashbacks
By Laurieann Chutis, A.C.S.W.

What are they?

Flashbacks are memories of past traumas. They may take the form of pictures, sounds, smells,
body sensations, feelings or the lack of them (numbness). Many times there is no actual visual or
auditory memory. One may have the sense of panic, being trapped, feeling powerless with no
memory stimulating it. These experiences can also happen in dreams.

As a child (or adolescent), we had to insulate ourselves from the emotional and physical horrors
of the trauma. In order to survive, that insulated child remained isolated, unable to express the
feelings and thoughts ofthat time. It is as though we put that part into a time capsule until it
comes out full-blown in the present.

When that part comes out, the little one is experiencing the past as if it were happening today. As
the flashback occurs, it is as if we forget that we have an adult part available to us for
reassurance, protection and grounding. The intense feelings and body sensations occurring are so
frightening because the feelings/sensations are not related to the reality of the present and many
times seem to come from nowhere.

We begin to think we are crazy and afraid of telling anyone (including our therapist) of these
experiences. We feel out of control and at the mercy of our experiences.

We begin to avoid situations, and stimuli, that we think triggered it. Many times flashbacks occur
during any form of sexual intimacy, or it may be a person who has similar characteristics to the
perpetrator, or it may b a situation today that stirs up similar trapped feelings ( confronting
aggressive people).

If you are feeling small ... you are experiencing a flashback.

If you are experiencing stronger feelings than are called for in the present situation ... you are
experiencing a flashback.

Flashbacks are normal

Vietnam vets have normalized this experience and have coined the term post traumatic stress
syndrome.

Even the diagnostic category book for psychiatry defines post traumatic stress syndrome as the
normal experience of all people experiencing an event that is outside the range of normal human
expenence.

Flashbacks feel crazy because the little one doesn't know that there is an adult survivor available
to help.
 Transference Issues in
Treating Incest Trauma
• Betrayal, disillusionment, mistrust
- criticism and judgement

• Traumatic transference
- you will do to me what others did
- you will be gratified by exploiting me

• Shame, self-hatred, and low self-esteem

• Interpersonal/intimacy difficulties

• Guilt, complicity, and responsibility

- sexual issues
- power issues

• Defenses, survivor skills, and accommodation

mechanisms

• Caretaking and learned responsibilities

• Loss and grief

- abandonment

• Rage and anger

- "I will endanger you with my story"

e 1988, 1989 C.A. Courtois

 •
Countertransferen ce Issues Ill
Treating Incest Trauma

• Denial, distancing, blame .• "We are all survivors"

• Guilt • Language muting

• Rage • Privileged voyeurism

• Dread and horror • Defens e like survivor's

• Shame • Conflict over professional

roles and boundaries
• Grief and mourning
• Sexualization or other
• Therapist as liberator ** exploitation of the
relationship
• Survivor as hero
(Adapted from Daniell, 1984)

.
** Therapist is not the parent and cannot make up for past losses. Losses
must be grieved. _ Therapist will be traumatized doing this work.
Therapist must decline being another sadistic abuser (Herman, 1987).

e 1988, 1989 C.A. Courtois ·

 Recommended Reading

1. The Courage to Heal: by Ellen Bass & Laura Davis

2. Secret Survivors: by E. Sue Blume

3. Adult Children of Abusive Parents: by Steven Farmer

4. Toxic Parents: by Susan Forward

S. Quick Steps to Resolving Trauma: by Bill O'Hanlon